1629384003 NPI number — MR. KENNETH W BOUDREAUX R.PH.

Table of content: MR. KENNETH W BOUDREAUX R.PH. (NPI 1629384003)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629384003 NPI number — MR. KENNETH W BOUDREAUX R.PH.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUDREAUX
Provider First Name:
KENNETH
Provider Middle Name:
W
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
R.PH.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629384003
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38 HAMMACK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALL
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71405-3261
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-640-4448
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 MILITARY HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINEVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-640-8066
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  10753 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1896781 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".